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Respite Care Services

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Creating Circles of Support for People with Developmental Disabilites and Their Families

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* For whom are you looking for housing?

Self

Other Relative

Spouse/Partner

Friend

Parent

Client

Grandparent

* Which best describes the current housing situation?

Live alone

Hospital

Home with spouse

Skilled Nursing Facility

Home with services

Retirement/Independent Living Community

Home with family support

Assisted Living/Residential Care Home

Living with family

None of the above

How will housing be paid for?

Private funds

Long term care insurance

Medicaid/public assistance

Veteran's Administration Benefits

Medicare

Combination of private funds and other sources

What is the monthly budget to spend on housing/care?

Under $1,000

$3,000 - $4,000

$1,000 - $1,500

$4,000 - $5,000

$1,500 - $2,000

$5,000 - $6,000

$2,000 - $3,000

Over $6,000

* How soon will housing be needed?

Right away

At least year from now

3-6 months

Not certain

6-12 months

Your contact information

* Full Name:

Phone #:

example: 201-555-1212

* E-mail:

Verification Code:

Creating Circles of Support for People with Developmental Disabilites and Their Families

9021 Ogden Avenue,
Brookfield, Illinois, 60513

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